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E STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 'pa0""Ors 0 • ,>a o m; • Cit 1.O -•ll' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNERS TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. /a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS Q 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ to MIDGRADE UNLEADED5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED Ed 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ® 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ® 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ® 95 UNKNOWN ® 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ® NO— D. EXTERIOR ® 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL, 8tC SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 l00% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 — -E LEAK �TECTWi 2 LINE TIGHTNESS 3 COMINUGUS NTERSTIT1AL 0 4 EL MONC U!ff NGNmkiING TESTING m"(ETECTOR 5 Aut ,1ATIC PUA� 99 OTHER SHutw" V. TANK LEAK DETECTION ® 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATTIIONORY ❑ 3 � T RING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUNDN TORING ®8 ANNUAL TESTING ❑ 7 MON TOROUS IN��AL ❑ 8 SIR ❑ 9 WEETANK GAUGING MONTHLY ❑ 10 TANK ❑ 95 UNKNOWN ❑ 99 OTHERTESTING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED b SIGNATURE) —7 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE LD.4 m 77M 11 11111 Ill 1-111 PERMIT NUMBER PERMIT APPROVED BY/OATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (6.95) F0RWUB.R7